Position statement - Sugar-sweetened beverages

Key messages

Cancer Council Australia recommends that the Australian Government introduce a targeted health levy on sugar-sweetened beverages, to effect a price increase of at least 20%. This levy should form part of a comprehensive approach to reducing sugar-sweetened beverage consumption, including restrictions on children’s exposure to marketing of these products, restrictions on their sale in schools, other children’s settings, and public institutions, as well as effective public education campaigns.

The consumption of sugar-sweetened beverages is associated with increased energy intake and in turn, weight gain and obesity. It is well established that obesity is a leading risk factor for diabetes, cardiovascular disease and 13 types of cancer.

Young Australians are very high consumers of sugar-sweetened beverages, and sugar-sweetened soft drinks in particular. The highest consumers of sugar-sweetened beverages are male adolescents (14 to 18 years of age), and males are higher consumers than females across all age groups.

The prevalence of sugar-sweetened beverage consumption is higher among lower socio-economic groups and Aboriginal and Torres Strait Islander people.

A range of factors influence the consumption of sugar-sweetened beverages, including taste, social settings, availability, price and marketing.

Added sugars and free sugars

There is increasing evidence to suggest that a high intake of added sugars (sugars added to foods and beverages by the manufacturer, cook or consumer) is associated with an increased risk of weight gain, as well as cardiometabolic problems such as diabetes[1]. Of particular concern is the adverse health impact associated with the consumption of added sugars in beverages such as soft drinks, which has been increasing globally over recent decades[2][3][4].

The World Health Organization (WHO) has recently published guidelines providing recommendations on the intake of free sugars (added sugars plus sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates) for adults and children, focused specifically on preventing and controlling unhealthy weight gain and dental caries[5]. The guideline strongly recommends a reduced intake of free sugars throughout the lifecourse, as well as reducing the intake of free sugars to less than 10% of total energy intake in both adults and children, or to 5% for the greatest health benefits[5].

'Sugar-sweetened beverages'

For the purpose of this position paper, ‘sugar-sweetened beverages’ refer to all non-alcoholic water based beverages with added sugar, including sugar-sweetened soft drinks and flavoured mineral waters, fortified waters, energy and electrolyte drinks, fruit and vegetable drinks, and cordials. This term does not include milk-based products, 100% fruit juice or non-sugar sweetened beverages (i.e. artificial, non-nutritive or intensely sweetened).

References to ‘fruit juice’ include 100% fruit juices and sugar added fruit juices unless otherwise stated.
These definitions have been developed from the literature on the influence of sugar-sweetened beverages and sugar-sweetened soft drinks on health and aim to reflect the data that exists in relation to consumption and sales in Australia
[6][7][8][9][10][11][12][13].

The health impacts of sugar-sweetened beverage consumption and dietary recommendations

Systematic reviews of the evidence have consistently found a significant association between sugar-sweetened beverage consumption and increased energy intake[10][11][14]. While various studies have found different effects and effect sizes (due largely to differences in study methodologies, sample characteristics and definitions in variables), there is also evidence of at least a probable association between sugar-sweetened beverage consumption and weight gain, body mass index, overweight and obesity (among adults and children)[9][10][11][14]. With respect to sugar-sweetened soft drinks in particular, research indicates that people do not compensate for the additional energy they consume from these drinks by reducing consumption of other foods, leading to increased total energy intake[10][15][16]. There is evidence that the increase in energy intake is greater than what can be attributed to these drinks alone, indicating that drinking sugar-sweetened soft drinks may lead people to consume more energy from other sources[9][10][15][17]. This may be because sugar-sweetened soft drinks stimulate appetite or suppress satiety[9][10][15][17].

In Australia, results from the National Nutrition and Physical Activity Survey (NNPAS) showed that in 2011-12, in females, consumption of sugar-sweetened beverages was higher in those who were overweight or obese compared with those who were underweight or normal weight (34% compared with 27%)[13]. In males however, sugar-sweetened beverage consumption did not differ greatly (approximately 40%) with varying body mass[13].

A systematic review undertaken in the United States estimated that the consumption of sugar-sweetened beverages had accounted for at least one-fifth of the weight gained between 1977 and 2007 in the US population (among persons two years of age and above)[14]. It has also been estimated that consuming one can of soft drink per day could lead to a 6.75 kg weight gain in one year if these calories are added to a typical US diet and not offset by reduction in other energy sources[18].

Leading international health organisations, including the WHO and World Cancer Research Fund (WCRF) consider sugar-sweetened beverage consumption to be a probable risk factor for weight gain and obesity[1][19]. WHO recommended that consumption of these beverages should be restricted and WCRF recommended that consumption should be avoided[1][19]. It is well established that obesity is a leading risk factor for a range of chronic diseases, including 13 types of cancer[19][20].

Systematic reviews and meta-analyses have found a significant relationship between the amount and frequency of sugar-sweetened beverages consumed and the increased risk of type 2 diabetes[10][21]. For example, it has been estimated that the risk of type 2 diabetes is 26% greater among the highest consumers of sugar sweetened beverages (most often 1–2 servings/day), compared to those with the lowest levels of intake (none or <1 serving/month)[21].

The consumption of added sugar by adolescents, with the greatest source being sugar-sweetened soft drinks, has been associated with multiple factors related to the increased risk of cardiovascular disease, including increased dyslipidemia (lower HDL ‘good’ cholesterol levels and higher LDL ‘bad’ cholesterol levels) among adolescents regardless of body size and increased insulin resistance among those that are overweight or obese[22].

Dental health in Australian children has declined over the past 20 years[23][24]. Studies have demonstrated an association between dental erosion and the amount and frequency of soft drinks and fruit juice consumed[9][1]. The WHO therefore recommends limiting soft drink and juice intake to minimise the occurrence of dental erosion[1].

The Australian Dietary Guidelines recommend limiting the intake of foods and drinks containing added sugars and in particular, limiting sugar-sweetened drinks[9]. These recommendations have been based upon evidence of a probable association (Grade B evidence) between sugar-sweetened beverage consumption and an increased risk of weight gain in adults and children[9]. They are also based upon evidence of a suggestive association (Grade C evidence) between soft drink consumption and an increased risk of dental caries in children, as well as an increased risk (from cola drinks) of reduced bone strength[9].

Cancer Council is concerned about high sugar foods and beverages because of their link to weight gain, not because they are direct cancer risk factors. While sugar-sweetened beverages may contribute to cancer risk through their effect on overweight and obesity, there is no evidence to suggest that these drinks are an independent risk factor for cancer[19].

How much do Australians consume?

There is evidence that sugar-sweetened beverages continue to be consumed by large numbers of adults and children in Australia[13], with a recent analysis of trends in sales of sugar-sweetened beverages worldwide showing that Australia is ranked 15th in the world for calories sold per capita per day[25].

Results from NNPAS showed that in 2011-12, 34% of Australians aged 2 years and over consumed sugar-sweetened beverages, with males more likely to consume these products than females (39% compared with 29%)[13]. Children aged 2-18 years consumed more sugar-sweetened beverages than adults (47% compared with 31%), with consumption peaking in those aged 14-18 years, with 55% of people in this age group consuming sugar-sweetened beverages[13]. A higher proportion of teenage males aged 14-18 years consumed sugar-sweetened beverages (62%) compared with females (48%). The most commonly consumed sugar-sweetened beverages were soft drinks and flavoured mineral waters (21%), followed by fruit and vegetable drinks (10%), and cordials (6%)[13]. Of those who consumed sugar-sweetened beverages, the median amount consumed was the equivalent of a regular can (375 mls), with males consuming more than females (437 mls compared with 350 mls)[13].

The results from a national survey of secondary students in 2012-13 (NaSSDA survey) showed that 22% of Australian secondary students reported consuming four or more cups (1L or more) of soft drink, cordial or sports drink per week, and that males were consuming higher quantities than females[26].

Comparisons between the NNPAS conducted in 2011-12 and the 1995 National Nutrition Survey have shown a reduction in the proportion of people aged 2 years and over who consumed sugar-sweetened beverages, from 43% in 1995 to 34% in 2011-12[13]. This was due largely to a decrease in consumption of cordial (from 15% in 1995 to 6% in 2011-12), with a decrease in consumption among children from 33% in 1995 to 10% in 2011-12. The most significant reduction in consumption of sugar-sweetened beverages was seen among children aged 2-3 years, where consumption fell by more than half (64% compared with 30%)[13]. It is important to note that some of the reduction in consumption of sugar-sweetened beverages observed between 1995 and 2011-12 may be due to apparent increases in under-reporting[13]. There appeared to be an increase in the level of under-reporting for males between 1995 and 2011-12, particularly for males aged 9-50 years, while the level of under-reporting by female respondents also appeared to have increased, but to a lesser extent than for males[13].

People from socially disadvantaged groups (across all age groups) are significantly higher consumers of sugar-sweetened beverages than those from higher socio-economic groups[8][12]. For example, the NNPAS in 2011-12 found that Australians living in areas with the highest levels of socioeconomic disadvantage were more likely to drink sugar-sweetened beverages than those living in areas of least disadvantage (38% in the most disadvantaged quintile compared with 31% in the least disadvantaged)[13]. Similarly, those living in areas with the highest levels of socioeconomic disadvantage consumed more of their dietary energy from added sugars than those living in areas of least disadvantage (10.3% in the most disadvantaged quintile compared with 8.3% in the least disadvantaged)[13].

In Australia, Aboriginal and Torres Strait Islander (ATSI) people have poorer health outcomes when compared with the rest of the population, and their relative socioeconomic disadvantage places them at greater risk of exposure to behavioural and environmental health risk factors. In 2012-13, results from the National Aboriginal and Torres Strait Islander Nutrition and Physical Activity Survey (NATSINPAS) showed that 50% of ATSI people aged 2 years and over consumed sugar-sweetened beverages, compared with 34% of non-Indigenous people (34%)[13]. In addition, for those who consumed sugar-sweetened beverages, the mean daily amount consumed was higher for ATSI people (450 ml), compared with the rest of the population (375 ml). Similar to the pattern observed in the general population, the consumption of sugar-sweetened beverages in ATSI people was highest in those aged 14-30 years (60%), falling to 25% in those aged 51 years and over[13]. The most commonly consumed sugar-sweetened beverages among ATSI people were soft drinks and flavoured mineral waters (37%), and approximately 15% of ATSI people consumed cordials which was double the rate of non-Indigenous people (7.5%)[13].

In 2011-12, Australians consumed an average of 52 grams of added sugars per day (equivalent to 12 teaspoons of white sugar), with the highest consumption of added sugars observed in those aged 14-18 years who averaged 73 grams per day (17 teaspoons)[27]. Non-alcoholic beverages were the largest source of added sugars (35%), with soft drinks and flavoured mineral waters providing 19%, followed by fruit and vegetable juices and drinks with 6%, and cordials with 5%. With regard to free sugars, 52% of Australians exceeded the WHO recommendation that free sugars contribute to less than 10% of total energy intake, and those most likely to exceed the recommendation were children and young people aged 9-13 and 14-18 years with approximately three-quarters of them receiving 10% or more of their energy from free sugars[27].

A recent study has examined the intake and sources of added sugars in a sample of Australian children and adolescents aged 2-16 years with plausible intakes based on 2 × 24 h recalls from the 2007 Australian National Children Nutrition and Physical Activity Survey[28]. Study participants consumed an average of 59 grams of added sugars per day, representing 12% of their daily energy intake[28]. Sugar-sweetened beverages (20%) were the top contributors of added sugars, representing 13% and 24% of added sugars intake in those aged 2-3 years and 14-16 years, respectively. Overall, boys received a significantly higher proportion of their added sugars intake from sugar-sweetened beverages compared with girls[28]. More than 80% of study participants exceeded the WHO recommendation that free sugars contribute to less than 10% of total energy intake[28].

What are the factors influencing sugar-sweetened beverage consumption?

Factors influencing sugar-sweetened beverages consumption across the population include taste, availability, role modelling by significant others, advertising and marketing, and price[12][29][30][31][32].

Among adults, social settings are key triggers for consumption, particularly where alcohol is consumed. The purchase of fast food and the availability of soft drinks in the home, workplace and other social settings are also leading factors[33]. Among children, the availability of sugar-sweetened beverages in the home and taste preferences are the main drivers of consumption[29][30][31]. The availability of sugar-sweetened beverages in schools is also a key driver[29], although many schools have now introduced restrictions on soft drinks being sold through canteens. A recent systematic review identified a number of determinants that were associated with higher sugar-sweetened beverage consumption in young children, including TV viewing/screen time, snack consumption and parents’ lower socioeconomic status[32].

Soft drinks are heavily promoted through media advertising, a wide variety of entertainment and sporting venues, children’s sports and events, targeting of schools, movie tie-ins and merchandise[12]. In 2012-2013, Coca Cola brands spent $23 million on media advertising in Australia[34]. The sponsorship of children’s sports and events is a key marketing technique used to reach children, and between 2010 and 2015 Coca Cola provided sponsorship for Australian schools, youth and community groups and sporting programs[35].

There is evidence from several systematic reviews that food and beverage marketing influences the types of food and beverages children prefer, demand and consume, and is likely to contribute to poor diets, negative health outcomes, weight gain and obesity in children[36].

Price also influences consumption of sugar-sweetened beverages[37][38]. A systematic review found that soft drinks and juice have high price elasticity of demand (i.e. a small change in price is accompanied by a large change in demand)[37]. After food purchased away from home, soft drinks are the category of food or beverage products most responsive to price changes[37]. There is evidence that a levy on sugar-sweetened beverages could reduce consumption and improve population health outcomes, if it was set at a sufficiently high level. The merits of an Australian health levy on sugar-sweetened beverages are discussed below.

The effectiveness of interventions to reduce sugar-sweetened beverage consumption

A comprehensive approach from Australian governments, schools, non-government organisations and others is required to improve diets and combat the problems of overweight and obesity[1][39]. Reducing the consumption of sugar-sweetened drinks in Australia will require bold regulatory reforms and a range of policies and programs aimed at the factors influencing consumption, such as marketing, availability and price[39].

Food and beverage advertising in Australia is currently regulated under a complex mix of statutory regulations and co- and self-regulatory codes[40]. However these regulations and codes are inadequate to protect children from the exposure and influence of sugar-sweetened beverage advertising as they do not restrict the volume of advertising that children are exposed to, nor do they adequately restrict the marketing techniques most commonly used to target children, such as the sponsorship of children’s sports, events and activities. There are also significant deficiencies in the administration and enforcement of the self-regulatory codes[40].

There is evidence that school-based programs can have a moderate impact (at least in the short term) on reducing children’s consumption of sugar-sweetened beverages, particularly when education campaigns and strategies to modify the environment are combined, and the strategies take a whole of school approach and extend to parents and families[41]. However school based programs are undermined by a range of other factors, including the promotion and ready availability of sugar -sweetened beverages outside of school grounds[41].

The 'Guidelines for healthy food and drinks supplied in school canteens' (as part of the National Healthy School Canteens project) aim to provide nationally consistent guidelines, building on state and territory based school canteen initiatives[42]. Under these national guidelines, sugar-sweetened beverages are not recommended for sale in school canteens. State governments have introduced their own policies banning the sale of sugar-sweetened beverages and other unhealthy foods in school canteens, but these policies may be being undermined by poor implementation and monitoring[43]. An evaluation in Victoria in 2010 found that banned foods continued to appear on 37% of Victorian government school menus, and of these menus, 63% continued to display banned beverages[43].

An Australian health levy on sugar-sweetened beverages

The Australian Government has acknowledged the need to improve the diets and health of Australians; however, to date few economic policies have been implemented in pursuit of that objective.

The WHO has recommended that governments consider economic tools, including levies and subsidies, to promote the consumption of healthier food products and discourage the consumption of less healthy options[44], and has suggested that there is sufficient rationale to implement a levy on sugar-sweetened beverages[45]. In Australia, a report of the National Preventative Health Taskforce has recommended that the government ‘provide disincentives for unhealthy foods by considering increasing taxes for energy-dense foods’[46]. As such, a health levy on sugar-sweetened beverages to increase their retail price and reduce consumption has been put forward as a potentially powerful policy intervention to improve diets and reduce the burden of chronic disease in Australia.

A recent study has estimated the impact of an additional 20% levy on sugar-sweetened beverages in Australia on health outcomes and expenditure. This study has shown that a 20% levy could reduce consumption of sugar-sweetened beverages by 12.6% and reduce obesity by 2.7% in men and 1.2% in women[47]. This study concluded that there would be sustained reductions in the incidence of diabetes, cardiovascular disease and some cancers, resulting in thousands of healthy life years gained and millions of dollars saved in healthcare costs. It was estimated that the levy could generate more than $400 million (AUD) annually in revenue even after the decline in consumption was taken into account[47].

Opponents of a levy on sugar-sweetened beverages, largely those within the beverage industry, have argued that it would be regressive and disproportionately impact those on lower incomes. However, Australians of low socioeconomic position are disproportionately affected by the high rates of chronic disease associated with poor diet, and are therefore likely to benefit most from a reduction in consumption of sugar-sweetened beverages. This is important because the costs of being overweight or obese falls mainly on the individual and their family. Of note, these groups are also more responsive to price increases and are therefore, more likely to reduce consumption and switch to water.

The significance of the financial regressivity of the levy has been challenged in a recent study[48]. This study demonstrated that while lower income households would pay a greater proportion of their income in additional tax, the financial burden across all households is small, with minimal differences between higher- and lower-income households (less than $5 USD per year)[48]. The impact of inequitable aspects of a levy on sugar-sweetened beverages would be further limited if the revenue generated was used to fund health promotion campaigns, or subsidies on healthy foods for low socioeconomic position households.

A levy on sugar-sweetened beverages would be relatively straightforward and inexpensive to administer, and there is strong public support for such a measure[49]. Research conducted on the attitudes of Australian grocery buyers found that 69% of participants supported the levy, provided the revenue was used to reduce the cost of healthy foods[49].

Policies in other jurisdictions

Sugar-sweetened beverage levies are now being introduced worldwide. Mexico introduced a levy of approximately 10% in January 2014, and by December 2014 the purchase of taxed beverages had fallen by 12%, while the purchase of untaxed beverages, largely bottled water, had increased by 4%[50]. Importantly, reductions in the purchase of taxed beverages were higher among low socioeconomic status households[50]. Health-related food levies targeting sugary drinks have also been implemented in France, Hungary, Chile, and a number of Pacific Island and Caribbean nations[51]. An impact of assessment of the Hungarian levy, which is applied based on the salt, sugar and caffeine content of a range of ready-to-eat foods including soft drinks, showed that one year after its implementation there was evidence of product reformulation by manufacturers[52]. In addition, sales of products subject to the levy fell by 27% and consumption of these products fell by 25-35%[52].

The UK has announced the introduction of a sugar-sweetened beverage levy from April 2018. Research indicates that a 20% levy on sugar-sweetened drinks would lead to a 1.3% reduction in the prevalence of obesity in the UK, with the greatest impact likely to be seen in young people, who are the largest consumers of sugar-sweetened beverages[53]. Modelling has shown that the implementation of sugar-sweetened beverage levies in India[54], New Zealand[55] and South Africa[56] would also have a positive impact on population health.

Cancer Council Australia’s recommendations

Cancer Council Australia recommends that adults and children should limit sugar-sweetened beverages and instead drink water or reduced-fat milk, in line with the Australian Dietary Guidelines.

Cancer Council Australia recommends comprehensive action by governments, schools, non-government organisations and others to inform the public about the health impacts of sugar-sweetened beverages and to influence the public to limit their consumption. A comprehensive approach should include:

The implementation of a sugar-sweetened beverage health levy by the Australian Government to effect a price increase of at least 20%, aimed at changing purchasing habits, achieving healthier diets and raising revenue for initiatives aimed at promoting healthy weight.

A social marketing campaign, supported by Australian governments, to highlight the health impacts of sugar-sweetened beverage consumption and encourage people to reduce their levels of consumption.

Comprehensive restrictions by Australian governments to reduce children’s exposure to marketing of sugar-sweetened beverages, including when large numbers of children are watching television, as well as through schools and children’s sports, events and activities.

Comprehensive restrictions by state governments on the sale of sugar-sweetened beverages in all schools (primary and secondary), places frequented by children, such as activity centres and at children’s sports and events (with adequate resources to ensure effective implementation, monitoring and evaluation).

An investigation by state and local governments into the steps that may be taken to reduce the availability of sugar-sweetened beverages in workplaces, government institutions, health care settings and other public places.